Guidelines Resuscitation and support of transition of babies at birth

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Guidelines: Resuscitation and support of 
transition of babies at birth
Authors
Jonathan Wyllie
Sean Ainsworth
Robert Tinnion
1. The guideline process 
The process used to produce the Resuscitation Council UK Guidelines 2015 has
been accredited by the National Institute for Health and Care Excellence. The
guidelines process includes:
Systematic reviews with grading of the quality of evidence and strength of
recommendations. This led to the 2015 International Liaison Committee on
Resuscitation (ILCOR) Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science with Treatment Recommendations.
1,2
The involvement of stakeholders from around the world including members
of the public and cardiac arrest survivors.
Details of the Guidelines development process can be found in the
Resuscitation Council UK Guidelines Development Process Manual. 
These Resuscitation Council UK Guidelines have been peer reviewed by the
Executive Committee of Resuscitation Council UK, which comprises 25
individuals and includes lay representation and representation of the key
stakeholder groups.
2. Introduction 
Until such time that the newly born infant has successfully made the transition to
air breathing it is dependent on the placenta and umbilical cord for respiration.
https://www.resus.org.uk/library/2015-resuscitation-guidelines/resuscitation-and-support-transition-babies-birth
https://www.resus.org.uk/library/publications/publication-guidelines-development-process-manual
The normal function of both of these may be interrupted by a number of
pathological events before or during the birth process (e.g. by placental
abruption, cord entanglement, etc.) giving rise to a hypoxic insult that may be
acute, chronic or both (acute on chronic).
Passage through the birth canal itself is a relatively hypoxic experience for the
fetus, since significant respiratory exchange at the placenta is interrupted for the
50–75 s duration of the average contraction.1 Although most infants tolerate this
well, the few that do not may require help to establish normal breathing at
delivery. The majority of these infants merely require supported perinatal
transition rather than ‘resuscitation’.
Resuscitation or support of transition is more likely to be needed by babies with
intrapartum evidence of significant fetal compromise, babies delivering before 35
weeks gestation, babies delivering vaginally by the breech, maternal infection
and multiple pregnancies.2 Furthermore, caesarean delivery is associated with
an increased risk of problems with respiratory transition at birth requiring
medical interventions3-6 especially for deliveries before 39 weeks gestation.
However, elective caesarean delivery at term does not increase the risk of
needing newborn resuscitation in the absence of other risk factors.7-10   
Some infants need support at birth for reasons other than hypoxia (e.g.
infection), however the initial approach to these infants follows the same
algorithm.
Newborn life support (NLS) is intended to provide this help and comprises the
following elements:
Enabling placental transfusion (when able to do so) by delaying the
clamping of the umbilical cord.
Drying and covering the newborn infant, and where necessary taking
additional steps, to maintain a normal body temperature (i.e. between
36.5°C and 37.5°C).
Assessing the infant’s condition and the need for any intervention.
Maintaining an open airway.
If the infant is not breathing, aerating the lungs with inflation breaths.
Continue ventilating apnoeic infants until respiration is established.
If the heart remains less than 60 min-1 after 5 effective inflation breaths and
30 seconds of effective ventilation, start chest compressions.
Administration of drugs (rarely).
3. Physiology of acute perinatal hypoxia 
If subjected to sufficient hypoxia in utero, or during passage through the birth
canal, the fetus will attempt to breathe. If the hypoxic insult is continued the
fetus will eventually lose consciousness. Shortly after this the neural centres in
the brainstem which control these breathing efforts will cease to function
because of lack of oxygen. The fetus then enters a period of absent respiratory
effort known as primary apnoea.
Up to this point, the heart rate remains unchanged, but soon decreases to about
half the normal rate as the myocardium reverts to anaerobic metabolism – a less
fuel-efficient process. The circulation to non-vital organs is reduced in an attempt
to preserve perfusion of vital organs. The release of lactic acid, a by-product of
anaerobic metabolism, causes deterioration of the biochemical milieu, adding to
the respiratory acidosis from the accumulation of carbon dioxide.
If the hypoxic insult continues, shuddering agonal gasps (whole-body respiratory
gasps at a rate of about 12 min-1) are initiated by primitive spinal reflexes. If the
fetus remains in utero, or if, for some other reason, these gasps fail to aerate the
lungs, they fade away and the fetus enters a period known as secondary, or
terminal, apnoea with no further spontaneous breathing. Until now, the
circulation has been maintained but, as terminal apnoea progresses, the rapidly
worsening acidosis, dwindling substrate for anaerobic metabolism and on-going
anoxia begins to impair cardiac function. The heart eventually fails and, without
effective intervention, the fetus dies. The whole process probably takes up to 20
min in the human fetus at term.
Thus, in the face of anoxia, the infant can maintain an effective circulation
throughout the period of primary apnoea, through the gasping phase, and even
for a while after the onset of terminal apnoea. Therefore the most urgent
requirement for any severely hypoxic infant at birth is that the lungs be aerated
effectively. Provided the infant’s circulation is functioning sufficiently well,
oxygenated blood will then be conveyed from the aerated lungs to the heart. The
heart rate will increase and the brain will be perfused with oxygenated blood.
Following this, the neural centres responsible for normal breathing will usually
function once again and the infant will recover.
Merely aerating the lungs is sufficient in the vast majority of cases.11 Lung
aeration and subsequent ventilation remains central to all efforts to resuscitate a
newborn infant, but in a few cases cardiac function will have deteriorated to such
an extent that the circulation is inadequate and cannot convey oxygenated blood
from the aerated lungs to the heart. In this case, a brief period of chest
compression may be needed as well as aeration of the lungs. In an even smaller
number of cases, lung aeration and chest compression will not be sufficient, and
drugs may be required to restore the circulation. The outlook in this group of
infants remains poor.
4. Important guideline changes 
The following are the changes that have been made to the NLS guidelines in
2015.12,13 Some build on or expand the changes that were introduced in 2010.
14,15
For uncompromised term and preterm infants, a delay in cord clamping of at
least one minute from the complete delivery of the infant is now
recommended. As yet there is insufficient evidence to recommend an
appropriate time for clamping the cord in infants who are severely
compromised at birth. For infants requiring resuscitation, resuscitative
intervention remains the immediate priority. Stripping (or ‘milking’) of the
cord is not recommended as a routine measure except in the context of
further randomised trials.
The temperature of newly born infants is actively maintained between
36.5°C and 37.5°C after birth unless a decision has been taken to start
therapeutic hypothermia. The importance of achieving this has been
highlighted and reinforced because of the strong association with mortality
and morbidity. Even the mild hypothermia that was once felt to be
inevitable and therefore clinically acceptable carries a risk. The admission
temperature should be recorded as a predictor of outcomes as well as a
qualityindicator.
Preterm infants of less than 32 weeks gestation may benefit from a
combination of interventions to maintain their body temperature between
36.5°C and 37.5°C after delivery through stabilisation and neonatal unit
admission. These may include: 
warmed humidified respiratory gases16
thermal mattress alone17
a combination of increased room temperature with plastic wrapping of
head and body with thermal mattress.18
All of these combinations have been effective in reducing hypothermia. In
addition, the delivery room temperature should be at least 26°C for the
most immature infants.
An ECG, if available, can give a rapid accurate and continuous heart rate
reading during newborn resuscitation.19 It does not, however, indicate the
presence of a cardiac output and should not be the sole means of
monitoring the infant.
Resuscitation of term infants should commence in air. For preterm infants, a
low concentration of oxygen (21–30%) should be used initially for
resuscitation at birth. If, despite effective ventilation, oxygenation (ideally
guided by oximetry) remains unacceptable, use of a higher concentration of
oxygen should be considered. Blended oxygen and air should be given
judiciously and its use guided by pulse oximetry. If a blend of oxygen and air
is not available use what is available. If chest compressions are
administered, supplemental oxygen should be increased.
Attempts to aspirate meconium from the nose and mouth of the unborn
infant, while the head is still on the perineum, are not recommended. The
emphasis should be on initiating lung inflation within the first minute of life
in non-breathing or ineffectively breathing infants and this should not be
delayed. If presented with a floppy, apnoeic infant born through thick
particulate meconium it is reasonable to inspect the oropharynx rapidly to
remove potential obstructions. Tracheal intubation should not be routine in
the presence of meconium and should only be performed for suspected
tracheal obstruction.
Nasal continuous positive airways pressure (CPAP) rather than routine
intubation may be used to provide initial respiratory support of all
spontaneously breathing preterm infants with respiratory distress. Early use
of nasal CPAP should also be considered in those spontaneously breathing
preterm infants who are at risk of developing respiratory distress syndrome
(RDS).12,13,20
The recommended compression: ventilation ratio for CPR remains at 3:1 for
newborn resuscitation. Asynchronous compressions are not recommended.
5. Suggested sequence of actions 
Below, you will find the Newborn Life Support algorithm, and under each heading
you'll find more information on the suggested sequence of actions.
Newborn life support algorithm
Keep the infant warm and assess 
Infants are born small and wet. They get cold very easily, especially if they
remain wet and in a draught. For uncompromised infants, a delay in cord
clamping of at least one minute from the complete delivery of the infant, is
recommended. Allowing placental transfusion ensures a more gradual transition
to extra-uterine life preventing sudden changes in venous return to the heart and
the potential impact of these on blood pressure.
Whatever the situation it is important that the infant does not get cold. In all
cases whether intervention is required or not, dry the term or near-term infant,
remove the wet towels, and cover the infant with dry towels. Significantly
preterm infants are best placed, without drying, into polyethylene wrapping
under a radiant heater. In infants of all gestations, the head should be covered
with an appropriately sized hat. The temperature must be actively maintained
between 36.5°C and 37.5°C after birth unless a decision has been taken to start
therapeutic hypothermia. The admission temperature should always be recorded
as a predictor of outcomes as well as a quality indicator.
This process will provide significant stimulation and will allow time to assess the
infant’s breathing, and heart rate. A note should be made of the colour and tone,
although these are of lesser importance in determining the immediate approach
to be taken they can point towards the severely acidaemic baby (potentially
requiring substantial resuscitation) or anaemic baby (potentially requiring urgent
transfusion).
Reassess breathing and heart rate regularly every 30 s or so throughout the
resuscitation process, but it is the heart rate which is the key observation. The
first sign of any improvement in the infant will be an increase in heart rate.
Consider the need for help; if needed, ask for help immediately.
A healthy infant will be born blue but will have good tone, will cry within a few
seconds of delivery and will have a good heart rate within a few minutes of birth
(the heart rate of a healthy newborn infant is about 120–150 min-1). A less
healthy infant will be blue at birth, will have less good tone, may have a slow
heart rate (less than 100 min-1), and may not establish adequate breathing by
90–120 s. An unwell infant will be born pale and floppy, not breathing and with a
slow, very slow or undetectable heart rate.
In the first few minutes, the heart rate of an infant is usually judged best by
listening with a stethoscope. It may also be felt by gently palpating the umbilical
cord but a slow or absent rate at the base of the umbilical cord is not always
indicative of a truly slow heart rate. Feeling for any of the peripheral pulses is not
helpful.
An ECG is the most accurate way to obtain a rapid and continuous heart rate
reading but may not be immediately available, nor will it give an indication of a
cardiac output.19 A pulse oximeter can give a continuous heart rate and
oximetry reading in the delivery room. With practice it is possible to attach a
pulse oximeter probe and to obtain a useful reading of heart rate and oxygen
saturation about 90 s after delivery.21
Airway 
Before the infant can breathe effectively the airway must be open. The best way
to achieve this is to place the infant on his back with the head in the neutral
position (i.e. with the neck neither flexed nor extended). Most newborn infants
will have a relatively prominent occiput, which will tend to flex the neck if the
infant is placed on his back on a flat surface. This can be avoided by placing
some support under the shoulders of the infant, but take care not to overextend
the neck. If the infant is very floppy (i.e. has no or very little tone) it is usually
necessary to support the jaw with a jaw thrust. These manoeuvres will be
effective for the majority of infants requiring airway stabilisation at birth.
    
Airway suction immediately following birth should be reserved for infants who
have obvious airway obstruction that cannot be rectified by appropriate
positioning and in whom material is seen in the airway. Rarely, material (e.g.
mucus, blood, meconium, vernix) may be blocking the oropharynx or trachea. In
these situations, direct visualisation and suction of the oropharynx should be
performed. For tracheal obstruction, intubation and suction during withdrawal of
the endotracheal tube may be effective. This latter manoeuvre should only be
performed by appropriately trained staff and, if performed, should not unduly
delay the onset of inflation breaths and subsequent ventilation.
Breathing 
Most infants have a good heart rate after birth and establish breathing by about
90 s. If the infant is not breathing adequately aerate the lungs by giving 5 
inflation breaths, preferably using air. Until now the infant's lungs will have
been filled with fluid. Aeration of the lungs in these circumstances is likely to
require sustained application of pressures of about 30 cm H2O for 2–3 s; these
are 'inflation breaths'. Begin with lower pressures (20–25 cm H2O) in preterm
infants.
   
Use positive end-expiratory pressure (PEEP) of 4–5 cm H2O if possible. It is of
demonstrable benefit in preterm infants but should also be used in term infants,
although evidence for itsbenefit in this group of infants is lacking from human
studies. If the heart rate was below 100 min-1 initially then it should rapidly
increase as oxygenated blood reaches the heart.
If the heart rate does increase then you can assume that you have
successfully aerated the lungs.
If the heart rate increases but the infant does not start breathing for
himself, then continue ventilations at a rate of about 30–40 min-1 until the
infant starts to breathe on his own.
If the heart rate does not increase following inflation breaths, then either
you have not aerated the lungs or the infant needs more than lung aeration
alone. By far the most likely is that you have failed to aerate the lungs
effectively. If the heart rate does not increase, and the chest does not
passively move with each inflation breath, then you have not aerated the
lungs.  
If the lungs have not been aerated then consider:
Checking again that the infant’s head is in the neutral position?
Is there a problem with face mask leak?
Do you need jaw thrust or a two-person approach to mask inflation?
Do you need a longer inflation time? – were the inspiratory phases of your
inflation breaths really of 2–3 s duration?
Is there an obstruction in the oropharynx (laryngoscope and suction)?
Will an oropharyngeal (Guedel) airway assist?
Is there a tracheal obstruction?
Check that the infant's head and neck are in the neutral position; that your
inflation breaths are at the correct pressure and applied for sufficient time (2–3 s
inspiration); and that the chest moves with each breath. If the chest still does not
move, ask for help in maintaining the airway and consider an obstruction in the
oropharynx or trachea, which may be removable by suction under direct vision.
An oropharyngeal airway may be helpful.
If the heart remains slow (less than 60 min-1) or absent after 5 effective inflation
breaths and 30 seconds of effective ventilation, start chest compressions.
If you are dealing with a preterm infant then initial CPAP of approximately 5 cm H
2O, either via a face mask or via a CPAP machine, is an acceptable form of
support in infants who are breathing but who show signs of, or are at risk of
developing, respiratory distress. In preterm infants who do not breathe or
breathe inadequately, you should use PEEP with your inflation breaths and
ventilations as the lungs in these infants are more likely to collapse again at the
end of a breath; using PEEP prevents this.
Chest compression 
Almost all infants needing help at birth will respond to successful lung inflation
with an increase in heart rate within 30 seconds followed quickly by normal
breathing.11,22-24 However, in some cases chest compression is necessary.
Chest compression should be started only when you are sure that the lungs have
been aerated successfully.
In infants, the most efficient method of delivering chest compression is to grip
the chest in both hands in such a way that the two thumbs can press on the
lower third of the sternum, just below an imaginary line joining the nipples, with
the fingers over the spine at the back. Compress the chest quickly and firmly,
reducing the antero-posterior diameter of the chest by about one third.25
The ratio of compressions to inflations in newborn resuscitation is 3:1.
Chest compressions move oxygenated blood from the lungs back to the heart.
Allow enough time during the relaxation phase of each compression cycle for the
heart to refill with blood. Ensure that the chest is inflating with each breath. You
should increase the oxygen concentration if you have reached this stage of
resuscitation. You should also have called for help, and a pulse oximeter, if not
already in use, will be helpful in monitoring how you are doing.
Do not use asynchronous compressions, even if the infant has a tracheal tube
placed, as maintaining air entry into the lung remains as important now as it was
during the initial aeration. Compressing the chest during a ventilation breath
may reduce air entry, which may be harmful.
In a very few infants (less than one in every thousand births) inflation of the
lungs and effective chest compression will not be sufficient to produce an
effective circulation. In these circumstances drugs may be helpful.
Drugs 
Drugs are needed rarely and only if there is no significant cardiac output despite
effective lung inflation and chest compression. The outlook for most infants at
this stage is poor although a small number have had good outcomes after a
return of spontaneous circulation followed by therapeutic hypothermia.
The drugs used include adrenaline (1:10,000), occasionally sodium bicarbonate
(ideally 4.2%), and glucose (10%). All resuscitation drugs are best delivered via
an umbilical venous catheter or if this is not possible through an intraosseous
needle.26,27
The recommended intravenous dose for adrenaline is 10 microgram kg-1 (0.1 mL
kg-1 of 1:10,000 solution). If this is not effective, a dose of up to 30 microgram kg
-1 (0.3 mL kg-1 of 1:10,000 solution) may be tried.
Adrenaline is the only drug that may be given by the tracheal route, although of
unknown efficacy at birth. If this is used, it must not interfere with ventilation or
delay acquisition of intravenous access. The tracheal dose is thought to be
between 50–100 microgram kg-1.
Use of sodium bicarbonate is not recommended during brief resuscitation. If it is
used during prolonged arrests unresponsive to other therapy, it should be given
only after adequate ventilation and circulation (with chest compressions) is
established. The dose for sodium bicarbonate is between 1 and 2 mmol of
bicarbonate kg-1 (2–4 mL kg-1 of 4.2% bicarbonate solution).
The dose for glucose (10%) is 2.5 mL kg-1 (250 mg kg-1) and should be
considered if there has been no response to other drugs delivered through a
central venous catheter.
Very rarely, the heart rate cannot increase because the infant has lost significant
blood volume. If this is the case, there is often a clear history of blood loss from
the infant, but not always. Use of isotonic crystalloid rather than albumin is
preferred for emergency volume replacement. In the presence of hypovolaemia,
a bolus of 10 mL kg-1 of 0.9% sodium chloride or similar given over 10–20 s will
often produce a rapid response and can be repeated safely if needed.
When to stop resuscitation 
In a newly-born infant with no detectable cardiac activity, and with cardiac
activity that remains undetectable for 10 min, it is appropriate to consider
stopping resuscitation. The decision to continue resuscitation efforts beyond 10
min with no cardiac activity is often complex and may be influenced by issues
such as the availability of therapeutic hypothermia and intensive care facilities,
the presumed aetiology of the arrest, the gestation of the infant, the presence or
absence of complications, and the parents’ previous expressed feelings about
acceptable risk of morbidity. The difficulty of this decision-making emphasises
the need for senior help to be sought as soon as possible.
Where a heart rate has persisted at less than 60 min-1 without improvement,
during 10–15 min of continuous resuscitation, the decision to stop is much less
clear. No evidence is available to recommend a universal approach beyond
evaluation of the situation on a case-by-case basis by the resuscitating team and
senior clinicians.
Communication with the parents 
It is important that the team caring for the newborn baby informs the parents of
the baby’s progress. At delivery, adhere to the routine local plan and, if possible,
hand the baby to the mother at the earliest opportunity. If resuscitation is
required inform the parents of the procedures undertaken and why they were
required. Record all discussions and decisions in the baby’s records as soon as
possible after birth.
6. Post-resuscitation care 
Therapeutic hypothermia
Term or near-term infants, with evolving moderate to severe hypoxic-ischaemic
encephalopathy, should be treated with therapeutic hypothermia.28-31Whole
body cooling and selective head cooling are both appropriate strategies.28-33
Cooling should be initiated and conducted under clearly-defined protocols with
treatment in neonatal intensive care facilities and the capabilities for
multidisciplinary care. Treatment should be consistent with the protocols used in
the randomised clinical trials (i.e. commence cooling within 6 h of birth, continue
the cooling for 72 h before re-warming the infant over a period of at least 4 h). All
treated infants should be followed longitudinally. Passive or active therapeutic
hypothermia should only be instituted following a senior clinical decision.
Glucose
Infants who are preterm or require significant resuscitation should be monitored
and treated to maintain blood glucose in the normal range. Hypoglycaemia
should be avoided in babies demonstrating signs of evolving hypoxic ischaemic
encephalopathy or who are undergoing therapeutic hypothermia. An infusion of
10% glucose rather than repeated boluses is usually best at treating low blood
glucose values and maintaining glucose in the normal range.
7. Explanatory notes 
Below, you'll find a series of explanatory notes on a variety of points covered in
this Guideline.
Resuscitation or stabilisation 
Most infants born at term need no resuscitation and they can usually stabilise
themselves during the transition from placental to pulmonary respiration very
effectively. Provided attention is paid to preventing heat loss (and avoiding over-
warming) and a little patience is exhibited before cutting the umbilical cord,
intervention is rarely necessary. However, some infants will have suffered
stresses or insults during labour. Help may then be required which is
characterised by interventions designed to rescue a sick or very sick infant and
this process can then reasonably be called resuscitation.
Significantly preterm infants, particularly those born below 30 weeks gestation,
are treated differently. Most infants in this group are healthy at the time of
delivery and yet all can be expected to benefit from help in making the
transition. Maintaining the temperature between 36.5°C and 37.5°C is even more
important than for term babies. Intervention in this situation is usually limited to
keeping an infant healthy during this transition and is more appropriately called
stabilisation. Gentle airway support using CPAP rather than ventilation may be
adequate for many of these infants. In the past both situations have been
referred to as resuscitation and this seems inappropriate and likely to cause
confusion.
Umbilical cord clamping 
For healthy term infants delaying cord clamping for at least one minute or until
the cord stops pulsating following delivery improves iron status through early
infancy.34 For preterm infants in good condition at delivery, delaying cord
clamping for up to 3 min results in increased blood pressure during stabilisation,
a lower incidence of intraventricular haemorrhage and fewer blood transfusions.
35 However, infants were more likely to receive phototherapy. There are limited
data on the hazards or benefits of delayed cord clamping in the non-vigorous
infant.36, 37
Delaying cord clamping for at least one minute is recommended for all newborn
infants not requiring resuscitation.12,13 At present there is insufficient evidence
to define an appropriate time to clamp the cord in infants who apparently need
resuscitation. However, this may be because time is the wrong defining
parameter and perhaps the cord should not be clamped until the infant has
started breathing (or the lungs are aerated). Stripping (or ‘milking’) of the
umbilical cord has been suggested as an alternative to delayed cord clamping
when the infant is in need of resuscitation; however, there is insufficient
evidence to recommend this as a routine measure. Umbilical cord milking did,
however, produce improved short-term haematological outcomes, admission
temperature and urine output when compared to delayed cord clamping in once
recent study.38
Maintaining normal temperature (between 36.5°C and 
37.5°C) 
Naked, wet, newborn infants cannot maintain their body temperature in a room
that feels comfortably warm for adults. Infants who are compromised are
particularly vulnerable to the effects of cold stress, which may will lower arterial
oxygen tension39 and increase metabolic acidosis.40 Active measures will need
to be taken to avoid hypothermia, especially in the preterm infant where a team
approach and a combination of strategies may be required. The neonatal unit
admission temperature of newborn infants is a strong predictor of mortality at all
gestations and in all settings.41-44 For each 1°C decrease in admission
temperature below this range there is an associated increase in mortality by 28%.
45  
Babies born outside the normal delivery environment may benefit from
placement in a food grade polyethylene bag or wrap after drying and then
swaddling.46,47 Alternatively, well newborns >30 weeks gestation who are
breathing may be dried and nursed with skin to skin contact or kangaroo mother
care to maintain their temperature whilst they are transferred.46-54 They should
be protected from draughts.
Recommendation
Unless you have decided to implement therapeutic hypothermia, take active
steps to maintain the temperature of the newly born infant between 36.5°C and
37.5°C from birth to admission and throughout stabilisation. If the resuscitation is
prolonged, consider measuring temperature during the resuscitation.
Oximetry and the use of supplemental oxygen 
If resources are available, use pulse oximetry for all deliveries where it is
anticipated that the infant may have problems with transition or need
resuscitation. Oxygen saturation and heart rate can be measured reliably during
the first minutes of life with a modern pulse oximeter. Data from healthy
spontaneously breathing infants has been used to inform when oxygen should be
given (see algorithm).55
The sensor must be placed on the right hand or wrist to obtain an accurate
reading of the preductal saturation.56,57 Placement of the sensor on the infant
before connecting to the instrument may result in faster acquisition of signal. In
most cases a reliable reading can be obtained within 90 s of birth.58 Pulse
oximetry can also provide an accurate display of heart rate during periods of
good perfusion.
In healthy term infants, oxygen saturation increases gradually from
approximately 60% soon after birth to over 90% at 10 min. In preterm infants
hyperoxaemia is particularly damaging and if oxygen is being used and the
saturation is above 95% the risk of hyperoxaemia is high. Therefore the rate of
rise in oxygen saturation after birth in preterm infants should not exceed that
seen in term infants, although some supplemental oxygen may be required to
achieve this.57,59
Colour 
Using colour as a proxy for oxygen saturation is usually inaccurate.60 However,
noting whether an infant is initially very pale and, therefore, either acidotic or
anaemic at delivery may be useful as an indicator for later therapeutic
intervention.
ECG monitoring of heart rate 
Clinical assessment of heart rate, whether by palpation of the cord or apex of the
heart or by listening with a stethoscope tends to be inaccurate.61,62 There is
increasing evidence supporting the use of ECG monitoring as a means of rapidly
determining the heart rate during resuscitation; it is quicker to provide an
accurate reading than pulse oximetry but does require that the ECG leads make
good contact with the skin.19,63
Airway suctioning with or without meconium 
Routine elective intubation and suctioning of vigorous infants at birth does not
reduce meconium aspiration syndrome (MAS).64 Nor does suctioning the nose
and mouth of such infants on the perineum and before delivery of the shoulders
(intrapartum suctioning).65 Even in non-vigorous infants born through meconium-
stained amniotic fluid who are at increased risk of MAS, intubation and tracheal
suctioninghas not been shown to improve the outcome.66-68 There is no
evidence to support suctioning of the mouth and nose of infants born through
clear amniotic fluid.
Recommendation
Routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants
born with clear and/or meconium-stained amniotic fluid is not recommended.
The practice of routinely performing direct oropharyngeal and tracheal suctioning
of non-vigorous infants after birth with meconium-stained amniotic fluid was
based upon poor evidence. The presence of thick, viscous meconium in a non-
vigorous infant is the only indication for initially considering visualising the
oropharynx and suctioning material, which might obstruct the airway. If an infant
born through meconium-stained amniotic fluid is also floppy and makes no
immediate respiratory effort, then it is reasonable to rapidly inspect the
oropharynx with a view to removing any particulate matter that might obstruct
the airway. Tracheal intubation should not be routine in the presence of
meconium and is performed only for suspected tracheal obstruction.68-72 The
emphasis is on initiating ventilation within the first minute of life in non-breathing
or ineffectively breathing infants and this should not be delayed, especially in the
bradycardic infant.
Laryngeal mask 
Several studies have shown that laryngeal mask airways (LMAs) can be used
effectively at birth to ventilate the lungs of infants weighing over 2000 g, greater
than 33 weeks gestation and apparently needing resuscitation.73-77 Case reports
suggest that LMAs have been used successfully when intubation has been tried
and failed – and occasionally vice-versa. One small randomised study has
suggested that LMAs may reduce the need for intubation compared to facemask
ventilation,78 however LMAs cost about three times as much and it is not clear
how many of the infants resuscitated using an LMA would have responded to
good quality facemask ventilation. Data on LMA use in smaller or less mature
infants are scarce.
Recommendation
Consider using an LMA during resuscitation of the newborn infant if face mask
ventilation is unsuccessful and tracheal intubation is unsuccessful or not feasible.
The LMA may be considered as an alternative to a face mask for positive
pressure ventilation among newborn infants weighing more than 2000 g or
delivered ≥34 weeks gestation.78 The LMA may be considered as an alternative
to tracheal intubation as a secondary airway for resuscitation among newborn
infants weighing more than 2000 g or delivered ≥34 weeks gestation.78 There is
limited evidence evaluating its use for newborn infants weighing <2000 g or
delivered <34 weeks gestation and none for those infants receiving
compressions.
Use of the LMA, nonetheless, should be limited to those individuals who have
been trained to use it. Its use has not been evaluated in the setting of meconium
stained fluid, during chest compressions, or for the administration of emergency
intra-tracheal medications.
Exhaled carbon dioxide 
Detection of exhaled carbon dioxide confirms tracheal intubation in neonates
with a cardiac output more rapidly and more accurately than clinical assessment
alone. It will not, however, distinguish between correct placement with the tip of
the tracheal tube in the trachea and incorrect insertion with the tip in the right
main bronchus (i.e. too long). False negative readings may occur in very low birth
weight neonates and in infants during cardiac arrest (in these cases a brief
period of chest compressions may bring about a colour change as more carbon
dioxide is delivered to the lungs). False positives may occur with colorimetric
devices contaminated with adrenaline, surfactant and atropine.
Drugs in resuscitation at birth 
Ventilation and chest compression may fail to resuscitate fewer than 1 in 1000
infants.23 In this group, resuscitation drugs may be justified. Whilst there is
evidence from animal studies for both adrenaline and sodium bicarbonate in
bringing about return of spontaneous circulation, there is no placebo-controlled
evidence in human infants for the effectiveness of any drug intervention in this
situation. Even for adults and children in cardiac arrest, there is insufficient
evidence to suggest that vasopressors improve long-term survival.
For this reason use of drugs before achieving lung aeration followed by chest
compressions (known to be effective resuscitative interventions) can never be
justified.12,13
Glucose 
Hypoglycaemia is associated with adverse neurological outcome in a neonatal
animal model of hypoxia and resuscitation.79 Newborn animals that were
hypoglycaemic at the time of a hypoxic-ischemic insult had larger areas of
cerebral infarction and/or decreased survival compared to controls.80,81
However, only a single clinical study has shown an association between
hypoglycaemia and poor neurological outcome following perinatal hypoxia.82 In
adults, children and extremely low-birth-weight infants receiving intensive care,
hyperglycaemia is associated with a worse outcome.80-84 However, in children,
hyperglycaemia after hypoxia-ischaemia does not appear to be harmful,85 which
confirms data from animal studies86 some of which suggest it may even be
protective.87 The situation remains unclear and unfortunately, the range of blood
glucose concentration that is associated with the least brain injury following
asphyxia and resuscitation cannot be defined based on available evidence.
8. Acknowledgements 
These guidelines have been adapted from the European Resuscitation Council
2015 Guidelines. We acknowledge and thank the authors of the ERC Guidelines
for Resuscitation and support of transition of babies at birth:
Jonathan Wyllie, Jos Bruinenberg, Charles Christoph Roehr, Mario Rüdiger,
Daniele Trevisanuto, Berndt Urlesberger.
 
9. Accreditation of the 2015 Guidelines 
NICE has accredited the process used by Resuscitation Council UK to produce its
Guidelines development Process Manual. Accreditation is valid for 5 years from
March 2015. More information on accreditation can be viewed at 
https://www.nice.org.uk/about/what-we-do/accreditation.
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